There is no “one right answer” when addressing the issue of Revenue Cycle Management during a government shutdown. Every agency must make its own business decisions based on its current situation. And as of October 6, 2025, “we don’t know what we don’t know, but there are some absolutes we can count on,” according to consultants at PWW Advisory Group (PWW|AG).
Some Absolutes During the Unknown
PWW|AG EMS & Mobile Healthcare Consultant Steve Johnson says, “One thing we do know with absolute certainty is that the least expensive way to process a claim always has been, and always will be, to handle it once. Every additional touch costs you real money.”
Johnson, who previously worked at a city-owned, third-service ambulance provider, and was also Director of Billing Services at an EMS Billing Service during previous shutdowns, stressed that “there’s no way I would be submitting Medicare claims with dates of service 10/1/2025 or later during this shutdown, unless I absolutely had to.”
“Admittedly,” he said, “an advantage I had [as a city-owned third-service provider], and that not everyone does, is that the city is not going to go broke or fail to meet payroll if I hold claims. So, long story short, if I can possibly cashflow it, the best thing I could do today is carefully manage everything else, including Medicare claims with a date of service prior to October 1, 2025, and wait and see on new Medicare claims.”
Each ambulance service must therefore decide for itself whether it has the resources and funds to support their operations during the shutdown while holding their Medicare claims, or whether their cashflow needs require them to submit claims for payment now, even if it means reprocessing later. This is an individualized determination that each ambulance service will have to make based on whether it is a private or public organization, whether it has cash reserves, tax support or a local subsidy, its payer mix, and a variety of other factors.
As many agencies have experienced, there are pitfalls when payers make mistakes, and every “reprocessing” is an opportunity for the payer to miss something and cause the agency to have to redo their claim again. When a payer processes a claim incorrectly, whether related to a government shutdown or not, the only thing a payment poster can do is post what they are given. This means if the payment for the Primary is incorrect, the Adjustment is incorrect, and any supplemental payment is incorrect. Yet the claim is closed and shows a $0.00 balance. Everything is great, until it isn’t.
How Claim Processing Mechanics May Work
There is a 14-day payment floor for FFS Medicare, but that doesn’t mean the MAC will “wait and see” for 14 days before processing the claim. Claims are processed as they come in (we know this because they immediately turn GY claims around during processing) and then they hold the payment until the floor date to release it. Unless the MAC pauses processing until the final answer is known on the fate of the add-ons and all the MACs systems are correctly updated, claims will likely be processed and paid based on the rates in effect today – not the rates that will (hopefully) apply once the ambulance bonus payments are extended.
Johnson outlined what could happen once the shutdown is resolved: “If they reinstate the add-ons retroactively, one of two things will happen for each payer involved in the claim:
- The provider will have to resubmit the claim for proper payment, or more likely
- Medicare will automatically reprocess the claim and send the provider a little more money — someday — when they get around to it. And then the EOBs will turn into a complete cluster of current claims and reprocessed claims. The amount of time it takes to even figure out what some of those things are can be ridiculous.”
What Could a BEST-CASE Scenario Look Like?
Johnson said, “Let’s say I’m lucky and my EOBs have great information on them — so that part is easy. Now I must reopen each closed claim and post the additional payment to it, which now creates a credit balance. Then I need to adjust the adjustment based on the new EOB, which leaves a balance owing from the Secondary that already paid. What do I do about that?”
“Yes, in the biggest mess we ever suffered through, the feds issued a waiver saying you didn’t have to collect the additional co-pay if you didn’t want to. But there are two problems with that. First, that was not a blanket policy for all claims now and in the future— it was specific to that situation. Secondly, that was at a time when we weren’t seeing ambulance services closing every week.”
Medicare Advantage – A Bigger Unknown
One of the larger hurdles agencies face today — which was not as significant years ago — is that more than half of all Medicare claims are now Medicare Advantage. With those, you run significantly more risks with each MA plan, such as:
- Will they cut the payments back, and if so, when?
- Will they calculate it correctly?
- If it’s fixed retroactively, how long will it take them to update their systems if they did make cuts?
Getting it Right the First Time Can Help
Of course, one big unknown is how long the shutdown will last. At this point, we don’t know. But one thing we do know is that the longer it lasts, the bigger the mess it creates.
Our team of consultants has been preaching “Right Day Billing” for several years now — usually regarding deductible status monitoring. Those principles apply here in a significant way. You can increase revenue by getting the Primary and Secondary payers to pay correctly the first time. You can reduce costs by having your staff post accurate payments to each account once.
The other unknown is whether the add-ons will ultimately be restored — and if so, whether they’ll be retroactive. Based on history, we tend to be optimistic, but we reserve the right to be wrong. Every agency must make that decision for itself.
As always, the entire PWW|AG team is monitoring this situation closely.
Please stay tuned and reach out to PWW|AG and its consultants for more information.
